Full Spectrum Health, LLC

307 E Northern Lights, Ste 201 Anchorage, AK 99503: www.fullspectrumhealthak.com: 907-229-9766

OFFICE POLICIES, GENERAL INFORMATION

Welcome to the Full Spectrum Health, LLC practice. This form provides you the client with information that is
additional to that described in the Notice of Privacy Practices. Please review carefully before signing and ask any
questions you may have. Once you have signed the document, it forms an agreement between you and your provider(s).
You will note that the office in which we meet is shared by other clinicians. We are both a group practice, and have
sole proprietors of independent businesses that also share space. However, we have signed agreements with one another
to maintain the privacy of our own and the other's clients for your protection.

The Process of Therapy: Psychotherapy requires your very active involvement, honesty, and openness to address
and/or change your thoughts, feelings, and behaviors. Attempting to resolve issues that brought you to therapy may
result in changes that were not originally intended. Psychotherapy may result in decisions about changing behaviors,
employment, substance use, schooling, housing, or relationships. Sometimes a decision that is positive for one family
member is viewed negatively by another. During therapy, your provider is likely to draw on various psychological
approaches according, in part, to the problem that is being treated and his or her assessment of what will best benefit
you. If you have any unanswered questions about any of the procedures used during your therapy, their possible
risks, or our expertise in employing them, please ask and you will be fully answered.

Each individual therapy provider has a unique set of skills, experiences and tools from which they will conduct your
therapy. Please discuss these considerations with your individual provider should you have any questions regarding
those topics. You always have the right to ask about treatment options, request a different type of treatment, or
discontinue therapy at any time.

Medication Management: For some clients, medications may be recommended as a part of their treatment plan
for the resolution of their current mental health symptoms, including, but not limited to symptoms that are
experienced by the patient because of traumatic experiences. It is the philosophy of this office that medications
are not a complete treatment plan for patients experiencing mental health concerns, but rather are incorporated
into a comprehensive plan based off the individual needs of the patient.

If your plan of care includes the use of controlled medication, you will need to understand that these medications cannot
always be submitted electronically. These medications are regulated by the Federal Government and have a high potential
for inappropriate activity. Prescriptions will not be provided for lost, stolen or misplaced controlled prescriptions.
Your provider has the discretion to decline to prescribe you controlled medication should they have concerns about the
ways in which you are using the medication . Please be aware that all providers have access to a state database which
will list your name, and any controlled prescription you have acquired anywhere in the State of Alaska. It is your
responsibility to arrange pick up of controlled medication prescriptions so that you do not run out of medication before
your next appointment. Please allow your provider at least 72 hours to respond to any medication refill request. Urgent
and emergent medication refills because of your poor planning are not the responsibility of this office or your provider.
We will attempt to respond to all medication refill requests as quickly as possible, but will have up to 72 hours (business
hours) to respond to all requests. Please do not rely on your pharmacy to submit your refill request. These requests are
often automatically generated and not reflective of current medication regimens. We do not always respond to pharmacy
requests that come without patient notification.

Your provider is often not immediately available by telephone as they are meeting with other patients. Currently, we have
limited front office staff, so please plan for your medication refills, records requests or other provider requests accordingly.
We will respond to records request within 30 days. Because evening and some Saturday appointments are offered, you will
get the office voicemail when you call outside stated business hours, and sometimes even during business hours. You may
leave a detailed message on the voicemail; however, it may take 24 to 48 hours for a return call depending on when you
leave your message. In case of emergency, please call 911 or call the mental health crises line at 907-563-3200 or go to your
closest emergency room.
 Full Spectrum Health, LLC
307 E Northern Lights, Ste 201 Anchorage, AK 99503: www.fullspectrumhealthak.com: 907-229-9766

Primary Care/Gender/SexualityAffirming Healthcare

We are honored that you have chosen to make Full Spectrum Health, LLC your medical home. Your primary care provider is trained
in the treatment of you as a whole person. All of our primary care providers have additional training specifically in working with the
LGBTQ+ community, and more specifically are sensitive to alternative lifestyles and relationship types, as well as have specific
training in gender affirming practices. On site laboratory and procedural services are available. All primary care services provided are
evidenced based and up to date according with current clinical guidelines. Please discuss your goals for healthcare with your
individual provider. Your signature on this policy form indicates a consent to treat you for primary care. Individual procedures and
informed consent for those said procedures will be conducted separately as needed. The policies listed above regarding medication
refills and records requests also apply to the primary care clinic.

Confidentiality: All information disclosed within sessions/appointments and the written records pertaining to those sessions
are confidential and may not be revealed to anyone without your consent, usually in writing, except where disclosure is
required or permitted by law. As indicated in the HIPPA agreement, suspicion of child abuse or neglect, and suicidal or
homicidal intent are considered required by law to report. Disclosure may be required pursuant to a legal proceeding. If you
place your mental status at issue in litigation or court proceeding, the defendant may have a right to obtain the psychotherapy
records and/or testimony by your therapist (please note that there is a charge a separate fee for court testimony). In couples
and family therapy, or when different family members are seen individually, confidentiality and privilege do not necessarily
apply between couples or among family members. The provider will use his or her clinical judgment when revealing
information.

Confidentiality of e-mail, cell phone, mail, phone and faxes communication: It is very important to be aware that email
and cell phone communication can be relatively easily accessed by unauthorized persons, and hence, the privacy and
confidentiality of such communication can be compromised. For this reason, I caution you against unsecure email as a means
of communication with clients. If I receive an email from you I will respond, but be aware of the consequences, and the fact
that another person may read your emails, especially if you email from a work account. You may leave me a confidential voice
mail at any time. I check my voice mail during regular business hours, which are Monday through Friday, 9am to 3pm. Please
do not use fax, email or voicemail for emergencies. If you elect to communicate with me by email at some point in our work
together , please be aware that email is not completely confidential. All emails are retained in the logs of your and my internet
service provider. While under normal circumstances no one looks at these logs, they are, in theory, available to be read by the
system administrator(s) of the internet service provider. Any email I receive from you, and any responses that I send to you,
will be printed out and kept in your treatment record.

Social Media: We do not use social media as a form of therapeutic communication. We do occasionally suggest an iphone or
android application that you might find helpful. These can include journal entries that you send to me via email. These are
not confidential documents, and you should be aware that we are not able to maintain your confidentiality should someone be
able to hack into your accounts or otherwise access your information through these apps. Parents, we sometimes shared these
app suggestions with your teens, please discuss the possibility with me.

Emergencies: If there is an emergency during our work together, or we become concerned about your personal safety, the
possibility or your injuring yourself or another person, we will do whatever we can within the limits of the law to ensure you
receive the proper medical care. For this purpose, we may also contact the person whose name you have provided on the
biographical sheet under the category of "emergency contact' .

General Emergency Procedures: If you need to contact me between appointments, please leave a message with the
answering machine at 229-9766 and your call will be returned as soon as possible. There may be times when we do not receive
your message or are unable to return your message on the same day you leave it. If an emergency situation arises, please
indicate that clearly on your message, but follow up to a call with the emergency services. Since we do not provide 24-hour
crisis coverage, both you and us need to be comfortable with your situation and circumstances in regards to this arrangement.
There is crisis coverage available city-wide, and, if this seems appropriate for you, then we can engage in a therapeutic
relationship. If you need to talk to someone right away, do not wait for a return call from me, but contact the 24-hour crisis
line at 563-3200 or the Police at 911.

Office Hours: Our clinic hours vary depending on the day and your provider may have their own individual schedule. As a
 Full Spectrum Health, LLC
307 E Northern Lights, Ste 201 Anchorage, AK 99503: www.fullspectrumhealthak.com: 907-229-9766
general rule of thumb, we are open M-F from 9a-5pm. We have administrative staff available M/W/F during those times. We
have limited weekend hours by appointment only.

Cancellations: Since scheduling of an appointment involves the reservation of time specifically for you, a minimum of
24 hours (1 business day) notice is required for re-scheduling or cancelling of an appointment.

This office does provide optional reminders by email. It is your responsibility to keep your scheduled appointment. If
you know that you will be unable to keep your appointment, kindly provide a minimum of 24 hours notice. All missed
appointments and appointments that are cancelled with less than 24 hours notice will be charged the full fee.
Insurance generally does not pay for missed appointments. All missed appointments must be paid prior to scheduling another
appointment time.

If we have to cancel an appointment that we have scheduled, we will make reasonable attempts to reschedule you as
soon as possible. It is our intention to end all sessions and phone calls at the scheduled time (appointments are
generally 30-60 minutes in length), and to be available for you at our scheduled appointment time. However, given the
nature of therapeutic work, there are times that we will be required to go over the scheduled time with another client,
which could run into the time that we had scheduled. Please know that in the event of need, we will do the same for
you.

Billing and Other Office Duties: We have someone on contract to assist with billing, filing, or other paperwork. If this
occurs, the person hired will sign a business associate's agreement that requires the highest level of confidentiality, thus
protecting your privacy. Currently our biller is Andrea Kirby. You can reach her at [email protected] please
inquire for her phone number. All other individuals who work or volunteer in this building, even if not a part of my office
staff, are required to sign this same agreement. This ensures your confidentiality in the event that someone working in the
building should see you before or after appointment times, or otherwise hear or see confidential information
inadvertently. There are a number of safeguards in place, however, to prevent this from occurring in the first place,
including double-locked file keeping practices, confidential voice mail, etc. Please inquire if you have any concerns related
to this issue.

Legal Proceedings (Custody Involvement, etc): Due to the nature of the therapeutic process and the fact that it often
involves making a full disclosure with regard to many matters which may be of a confidential nature, it is strongly
suggested that should there be legal proceedings (such as, but not limited to divorce and custody disputes, injuries,
lawsuits, etc.), neither you (client), nor your attorney, nor anyone acting on your behalf call on me to testify in court or
at any other proceeding, nor request a copy of the psychotherapy records. This action can be particularly harmful to
children who believe they are sharing information in a safe place that is then revealed in court. Court testimony can and
often does damage a child ' s trust in their therapist and usually ensures that at least one parent - generally the one that the
child expresses the most anger, discomfort, or

difficulty with - will believe that we are not doing a good job with the child. A therapist and a child custody evaluator
are not the same thing and should not be treated as such. If we are requested or subpoenaed to court on your behalf,
please note that we charge a
$700.00 flat fee and $300.00 per hour for court appearances/testimony, with a $1000.00 minimum. This fee will be
assessed if we are scheduled for court on your behalf, and is not contingent upon our actual participation or
testimony. This fee is based on current client contract fees, and is not an expert witness fee. Please contact me
separately for information about expert witness testimony.

Arbitration. Binding arbitration is the exclusive means of resolving any dispute unrelated to medical malpractice,
including tort claims but excluding small claims matters and actions for equitable relief. Alaska’s Revised Uniform
Arbitration Act (AS §09.43.300 to .595) and all subsequent arbitration statutes govern the arbitration proceedings. The
arbitration proceedings are to take place in Anchorage, Alaska. In the event of dispute that is not covered under
arbitration, the Parties hereby submit to the exclusive jurisdiction of the federal and state courts in Anchorage, Alaska.
 Full Spectrum Health, LLC
307 E Northern Lights, Ste 201 Anchorage, AK 99503: www.fullspectrumhealthak.com: 907-229-9766
A party shall initiate arbitration by sending a notice to the other party describing the controversy and remedy sought
and providing a list of five arbitrators listed in the Alternative Dispute Resolution section of the most recent edition of
the Alaska Directory of Attorneys published by Todd Communications or its successor. The initiating party shall serve
this notice with the list of arbitrators under the notice provision in this agreement. The party receiving the notice shall

give notice of its selection of an arbitrator from the list of arbitrators within 10 days of receiving the notice. If the
receiving party fails to select an arbitrator within that timeframe, then the initiating party shall choose the arbitrator
from the list. The party who does not prevail in the arbitration shall pay all of the prevailing party’s actual attorney’s
fees and costs related to the arbitration. A claim sought to be arbitrated is subject to the same limitations of time for the
commencement of actions as if the claim had been asserted in a court. The parties shall give all notices required in this
agreement to the addresses specified above as follows (deemed received as specified in parentheses): by hand (upo n
delivery), via overnight FedEx or UPS (24 hours after deposit), by email (with email confirmation from recipient), or
by first class certified or registered mail, return receipt requested, postage prepaid (48 hours after deposit in the mail).

Payments and Insurance Reimbursement: Every client will undergo a psychiatric diagnostic assessment for their first
appointment:

Clients are expected to pay the full fee for the appointment at the time of service. Please inquire about visit costs ahead of
time if you would like more information. We would also recommend that you ask your insurance company ahead of time to
ensure that the codes are covered. Payment is expected at the time of service. If we are courtesy billing your insurance company
for you, your portion of the payment will be due at the time of service, or, if you prefer, we will send you a monthly bill. You
can pay this bill in person, via check or credit card, use the credit card authorization form given to you at intake, or pay in cash.
If your account becomes more than 60 days past due, a payment plan must be established. Any overdue bills will be charged 2%
per month interest after 60 days. If after 90 days the account continues to be delinquent and you have made no effort to establish a
payment plan or to abide by the payment plan, we reserve the right to discontinue services, and your account may be turned over
to a collection agency. Fees are subject to change with two weeks prior notification.

Clients who carry insurance are asked to kindly remember that professional services are rendered and charged to the
client and as such you will be ultimately responsible for the full payment of services rendered in the event that your
insurance company denies any claim or reimbursement. As was indicated in the section, Health, Insurance and
Confidentiality of Records, you must be aware that submitting a mental health invoice for reimbursement carries with it a
certain amount of risk. Not all issues/concerns/problems which are the focus of psychotherapy are reimbursed by
insurance companies. It is your responsibility to verify the specifics of your coverage. It is possible that preauthorizing
with your insurance company will result in a higher reimbursement rate or more therapy sessions. Please contact your
insurance company prior to or directly after our first meeting if you have not already done so, to verify the specifics of
your coverage.

Printed name of patient: __________________________

Signature of patient/guardian:

Date: _____________________

Revised 04/2018